CARE Team Referral Form

Please use the form below to report any behavior(s) of concern to the CARE Team. The team will assess the information and follow up with you and/or the person of concern as appropriate. (Fields marked with an asterisk (*) are required fields and cannot be left blank.)

Your Information

*Full Name

Work Phone

Required format 000-000-0000

Home Phone

Required format 000-000-0000

Cell Phone

Required format 000-000-0000

*Email

Information About Person of Concern

*Full Name

ID Number

If applicable.

*Severity Level

*BehaviorChoose as many as apply.

Agitation

Aggression

Anger

Anxiety

Depression

Emotional Instability

Hyperactivity

Impulsive Behavior

Isolation

Self-Blame

Self-Harm

Other (If "Other", please explain below.)

*Observation Date(s)

If multiple observation dates, enter each date followed by a semicolon [ ; ].

*Observation Time(s)

If multiple observation times, enter each time followed by a semicolon [ ; ].

*Observation Location(s)

If multiple observation locations, enter each location followed by a semicolon [ ; ].